How to deal with arrogant, all knowing doctors

KUDOS TO THE ADMINS

I have to give kudos where kudos are due. I have to give kudos to the ER boss and the nurses of the ER for listening to and incorporating the advice of this and other RTs.

As I have written on this blog before, it was getting to the point that EKGs were ordered for such frivolous orders, or the patient wasn't available when the RT dropped what he was doing and rushed to ER, that many of us RTs stopped rushing to do EKGs in the ER.

It got to the point our EKG response time was really bad, like 20 minutes. That's not good, especially when you have a patient who is having life threatening chest pain -- or an MI (a heart attack). In these situations, an EKG should be done within 10 minutes from the time the patient entered the door.

ACLS also recommends such EKGs be done within 10 minutes. Yet, still, there were so many stupid EKG orders that we RTs stopped rushing down. I suppose they desensitized us to the word STAT.

Now, I recommended to my RT Boss that ER should call us stat for ACLS EKGs, and ASAP for all others. That way we can prioritize, and if we can't get down right away we can call and the ER staff can do the EKG. My boss said, "There is no reason you should ever not get down to ER right away to do an EKG."

That ended the discussion. A while later I talked to the ER Boss, and she liked my idea. But, five years later, nothing ever changed.

Now, however, my idea is implemented and going well. The door to EKG time has improved from 20 minutes three months ago to 8 minutes. That's great.

In fact, yesterday one of the nurses pointed me to a sign on the window that notified us of this great improvement, and the nurse said, "Kudos to you."

I said, "No! Kudos to you and your boss."

I meant that. Now that the ER staf page us RTs STAT for procedures that should be done STAT, we know that when we get paged STAT it means STAT.

Of course it took money for the change to finally be implemented. Six months ago the head RN boss noticed that insurance companies will pay for any EKG on patients over 29 complaining of atraumatic chest pain. She also noticed that they weren't paying for most of our EKGs because the door to EKG times were way too often greater than 10 minutes.

So, she got one member from each department together at a meeting to determine what could be done to speed up the time from door to EKGs.

I was picked by the RT boss to represent the RT Cave. My suggestion was simple: "Call us STAT only for ACLC EKGs. In other words, call us STAT for Atraumatic Chest Pains."

The idea was implemented. And, no surprise, it works. We RTs are happy because we know exactly when we need to rush, the nurses are happy because they no longer have to complain we took too long, and the RT Bosses are happy because they get paid."

So, kudo's to the bosses at Shoreline Medical Center. You've earned it.

Sigh!!!

She sat in a chair next to her mother's bed. Her mom was a long time smoker/ old alcoholic with a boat load of problems, the least of which was her Hepatitis which caused her skin to turn yellow.

The daughter said: "This is a breathing treatment, mom. It's going to help get some of the fluid out of your lungs so you can breath better."

"No it's not," I said bluntly.

"Oh, well, it's going to make your heart pump better so you can breath better."

"No it's not," I said, bluntly.

"Oh, that's what the doctor said?" She looked at me blankly.

"Well," I said, "I guess the doctor was wrong then. This medicine is a bronchodilator that dilates the bronchioles if your mom is having bronchospasm."

"Oh... Oh, okay..."

The funny thing is, I don't doubt the doctor did tell her that. The unfunny thing is I get tired of explaining this every day.

The common sense approach to hard luck asthma

A hard luck asthma patient came to see me in the ER last night. She had asthma so bad she actually spent some time at National Jewish recently (she hated the place). Since I was an asthma patient there in 1985 for six months, we had a nice chat.

That aside, after several breathing treatments I found myself standing behind the nurses station. The doctor (Dr. Q1) was concerned by something the patient said to her, which was this: "I gave myself 25 mg of solumedrol 2 days ago, and today I put myself on 80mg. Obviously it didn't work."

The doctor said to me, "She shouldn't be medicating herself like that without a doctor's order."

"Why not," I said. "I used to do that when my asthma was bad every day."

"You used to abuse your medicine?" Her stare was blank.

"Is it abuse?"

"Well yes it's abuse."

"I used to adjust medicine when I was having trouble breathing. If I didn't do things like that I would have ended up in the ER every week of my life. And since I'm not on welfare, I can't afford that. "

"But that's against the asthma guidelines."

"No it's not. The asthma guidelines are guidelines. They also recommend the doctor and patient work together on developing an asthma action plan individualized for the asthma patient. There are some hard luck asthmatics who can be trusted to treat themselves at home. When the said treatment doesn't work, they come to the ER -- like this patient did."

"I don't like that," the ER doc said.

There are many asthma action plans that allow for asthmatics to have a prescription of oral corticosteroids to keep in the medicine cabinet. When the asthma flares up the patient may self medicate and call the doctor.

If it works the patient avoids another expensive hospital visit. If it doesn't, then the patient has someone drive her to the ER, which is exactly what my patient did last night.

I respect Dr. Q1 in that she does a great job with her patients. But her inflexible methodologies of treating patients means that all patients get treated alike, and the ideal therapy for the patient may be overlooked.

Then again, this is the same doctor who believes only doctors are capable of determining what patients need breathing treatments and how often (usually Q1).

NO duragesics in the mouth -- okay

I was called to ER because we had an OD patient being wheeled in. The EMT was bagging. I assisted with the scooch over from the EMT cart to the ER bed. Then I took over bagging.

"Oh, not again," I thought. "I'm so sick of being busy all night because some person tries to kill herself."

The patient was vomiting. Oh, if that's not the grossest part of this job I don't know what is.

She still wasn't breathing, so as soon as she was done I rolled her back to her back and started bagging again. But, as soon as that Narcan was given, the patient was breathing again.

Dr. Click ordered for an NG, but as it was being inserted the patient started vomiting again. She vomited and vomited and vomited until there was a humungous pile of puke sitting there on the bed, floor, patients hair and everywhere.

"Oh, I think I'm going to puke," Dr. Click said. She looked like she might puke too, except for her smile. She was a cutie doctor.

Anyway, by the time she was done puking that second I looked up at the doc and said, "So, I bet we don't need to tube her now."

"No," she said, "I think what we were trying to prevent already happened."

Later, when the patient was being wheeled up to the critical care, she said she was in so much pain she put the duragesic patch in her mouth. She passed out.

The EMT later told me when they arrived the patient was lying on the floor all cyanotic and all, and the family was on the couch watching her. One of them said, "Yeah, I think she OD'd again."

The patient later admitted, "I was just in a lot of pain. I wasn't trying to kill myself."

In the hospital you never see it all.

A good feeling for a humble RT

On the technical side of being an RT, one of the greatest joys is when you intubate a patient, and set up a vent based on your protocol and experience and common sense, and then you tell the doctor what you did and why.

"That sounds great," the doctor says. "Just try to keep the EtCO2 around 30."

Awesome, I think. So I titrate the rate and title volume a bit until that EtCO2 is just where the doctor wants it, and then turn down the FiO2 until the SpO2 is no longer 100%.

This is how it should be. This is awesome.

Tonight when I learned that a bad baby was coming to our ER, and the nurse told me how much the baby weighed, I grabbed my little cheat sheet and knew, based on our protocol, that I needed a 3.5 ETT and that it should be positioned approximately about 9-10 at the lip.

Once the doctor was done intubating, I said, "I think it should be 9-10 at the lip."

"No, I want it at 12," she said.

I listened for lung sounds and told her lung sounds were diminished on the left. She pulled it back to 11. "I don't want to pull out any further," she said. "Let's secure it right here."

Later, after we had secured that little tube with tons of sticky tape, the doc looked at the x-ray results. "Well, I think we need to pull it back to 9 or 10," she said.

I couldn't help but smile. She knew I was right.

A good feeling for a humble RT.